2nd
March: CMAAO Updated COVID 19
Dr KK Aggarwal
President
CMAAO, HCFI and Past national President IMA
Breaking News: A 34-year-old
Kerala man who returned from Coronavirus-hit Malaysia died with pneumonia and
diabetic ketoacidosis in Ernakulam government hospital in Kochi a
day after he tested negative for the deadly coronavirus.
Why WHO is
shying in declaring it a pandemic: 67 countries; six of seven continents; community spread; no immunity in public; more cases
in S Korea (1062), Italy (566) and Iran (385) than in China (202) Yesterday; deaths
in 10 countries; 9039 cases outside China
Update: 67 countries, 88,583 cases, 3043 deaths,
45089 recovered, 40,462
Currently Infected Patients, 33,109 (82%)
in Mild Condition, 7353 (18%) Serious or Critical, likely deaths ( 3043 + 7353 x 15 =1103) = 4146 with
the present trend and available treatment,
COVID 19 SUTRAS
·
Possibly behaves like SARS; near pandemic in 30 days. causes
mild illness in 82%, severe illness in 15%, critical illness in 3% and death in
2.3 % cases ( 15% of admitted serious
cases, 71% with comorbidity, 10% in Iran); affects all ages but predominately
males ( 56%, 87% aged 30-79, 10% aged < 20, 3% aged > 80); with variable
incubation period days ( 2-14; mean 3
based on 1,324 cases, 5.2 days based on 425 cases, 6.4 days in travellers from Wuhan); mean time to symptoms 5 days, mean time to pneumonia 9 days, mean time to
death 14 days, mean time to CT changes 4
days, 3-4 reproductive number R0 ( flu 1.2, SARS 2), epidemic doubling time
7.5 days ( Korea 1 day probably due to super spreader), Tripling time in Korea
3 days, Positivity rate ( UK 0.2%, Italy
5.0%, France 2.2%, Austria 0.6% and USA 3.1% ;
has origin possibly from bats (mammal), spreads like large droplets and
predominately from people having lower respiratory infections and hence
standard droplet precautions the answer for the public and close contacts and
air born precautions for the healthcare workers dealing with the secretions.
·
Clinically all patients have fever, 75% have cough; 50%
weakness; 50% breathlessness with low total white count and deranged liver
enzymes. 20% need ICU care and 15% of them are fatal. Treatment is symptomatic
though chloroquine, anti-viral and anti-HIV drugs have shown some efficacy.
·
Only 20% will have symptoms and will go for
testing, rest may self-quarantine, 15% of serious will die. In Iran 16 died of 95 tested means they are
only testing serious patients.
What is
COVID 19?
·
Disease: coronavirus disease or (COVID-19) [11th
February]
·
Virus: severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) [11th February] Earlier name 2019 novel
coronavirus. It is more close to SARS with many aspects.
·
Name:
as per WHO guidelines previously
developed with the World Organisation for Animal Health (OIE) and the Food and
Agriculture Organization of the United Nations (FAO).WHO policy is not linking the name to a person, animal, place
or country.
·
WHO also refer the virus as “the virus responsible
for COVID-19” or “the COVID-19 virus” when communicating with the public.
Is it in
a pandemic state?
·
As per WHO and CDC pandemic declaration is
likely. WHO says outbreak is “getting bigger”, can spread worldwide and is “literally knocking
at the doors?”
·
On 21st Feb CDC said it is a Pandemic Alert and a
tremendous Public Health Threat.
·
Who said, "… we are concerned about the number of cases
with no clear epidemiological link, such as travel history to China or contact
with a confirmed case".
·
Community spread: Cases are detected in Singapore,
South Korea, Taiwan, Vietnam, Hong Kong and Japan in community where it's not
known what the source of the infection was.
·
24th Feb: We're in a phase of preparedness
for a potential pandemic.
·
25th Feb: Preparing for community
transmission of the COVID-19 coronavirus
·
Feb 29: WHO raises Global Risk from Coronavirus to the highest
level of alert “We have now increased our
assessment of the risk of spread and the risk of impact of COVID-19 to very high at global level,”
·
WHO: “If we don’t act... that may be a future
that we have to experience,” “a lot of the future of this epidemic is in the hands of ourselves?” [
·
29th Feb first US death in a patient with a
community spread case.
What is a pandemic?
·
WHO: "the worldwide spread of a new disease"
and ability to spread from person to person.
·
CDC: Spreads across "several countries or
continents, usually affecting a large number of people.
·
UK's Health and Safety Executive: Virus markedly
different from recently circulating strains and humans have little or no
immunity to it.
What is coranxiety?
Anxiety about falling ill and dying;
avoiding or not approaching Healthcare facilities due to fear of becoming
infected during care; fear of losing livelihood; fear of not being able to work
during isolation; fear of being
dismissed from work if found positive; fear of being socially excluded; fear of
getting put into Quarantine; fear of being separated from loved ones and
caregivers due to quarantine; refusal to take care of unaccompanied or
separated minors; refusal to take care of people with disabilities or elderly
because of their high- risk nature; feeling of helplessness; feeling of boredom;
feeling of depression due to being isolated; stigmatization of being
positive infection; possible anger and aggression against government; unnecessary
approaching the courts, possible mistrust on
information provided by government. relapses of mental illness in already
mental patients; overstress on people to cover work of infected colleagues,
quarantined for 14 days and insufficient or incomplete information leading to
myths and fake news.
If the anxiety is not tackled what
will happen?
Normal people will buy
masks, get the tests done, get admitted and finish resources meant for high
risk persons.
How many
countries and continents are affected as on today?
Does it
affect the doctors also?
As on 14th
Feb, 1,716 medical workers
have contracted the virus and six died in China. 1,502 were in Hubei Province,
with 1,102 of them in Wuhan. The number represent 3.8% of China’s overall
confirmed infections as of Feb. 11 with 0.3% deaths. (18th Feb:
Director of Wuhan Hospital died). Over
3000 workers involved so far. 2 workers who were
sent to Wuhan in January end to help build new hospital got infected.
What is the seriousness profile?
It causes mild illness in 82%, severe illness in 15%,
critical illness in 3% and death in 2.3 % cases. About 6% patients admitted in ICU require mechanical
ventilation, or died [NEJM]
How many deaths occur in patients without
comorbidity?
No deaths have occurred among those with mild or
even severe symptoms.
How much time it takes to recover?
People with mild cases recover in about two weeks, while those who are
sicker can take anywhere from three to six weeks.
In which cases it is riskier?
It caused death in 15% of admitted serious cases. 71% deaths are in patients with comorbidity. [
72,314 Chinese cases, largest patient-based study, JAMA)
COVID-19 Fatality Rate by
COMORBIDITY:
Percentage
does NOT represent in any way the share of deaths by pre-existing
condition. Rather, it represents, for a patient with a given
pre-existing condition, the risk of dying if
infected by COVID-19.
Pre-existing
condition Death Rate/confirmed
cases Death Rate/ all cases
Cardiovascular
disease 13.2% 10.5%
Diabetes 9.2%
7.3%
Chronic
respiratory disease 8.0% 6.3%
Hypertension
8.4% 6.0%
Cancer
7.6% 5.6%
no
pre-existing conditions 0.9%
What is
the case fatality of COVID 19?
·
2%
overall
· Wuhan 4.9%
· Hubei Province 3.1%
· Nationwide in China 2.1%
· Other provinces 0.16%.
· NEJM: 1,099 cases from China, finds a lower rate:
1.4%. The death rate may be even lower, if there are many mild or symptom-free
cases that have not been detected. The true death rate could turn out to be like that of a severe
seasonal flu, below 1
percent.
·
Case fatality 10% in Iran, probably
they are underreporting mild cases.
Why did the first Chines doctor die?
Li Wenliang, 34, perhaps,
while treating patients was exposed to a large blast of the virus.
What is
the case fatality as per the age?
The % shown do not have to add up to 100%, as they do NOT represent share of deaths
by age group but represents, for a person in a given age group,
the risk of dying if infected.
AGE Death Rate/ Confirmed cases Death rate/ all cases
80+
21.9% 14.8%
70-79
8.0%
60-69
years old 3.6%
50-59
years old 1.3%
40-49
years old 0.4%
30-39
years old 0.2%
20-29
years old 0.2%
10-19
years old 0.2%
0-9
years old no
fatalities
What is the
case fatality of other viruses?
· MERS 34% (2012, killed 858 people out of the 2,494 infected)
· SARS 10% (Nov. 2002 – Jul. 2003, originated from Beijing, spread to 41 countries, with
8,096 people infected and 774 deaths).
·
Ebola
50%
·
Smallpox
30-40%
·
Measles
10-15% developing countries
·
Polio
2-5% children and 15-30% adults
·
Diphtheria
5-10%
·
Whooping
cough 4% infants < 1yr, 1% children < 4 years
·
Swine
flu < 0.1-4 %.
·
Seasonal
flu 0.01%
· Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths
per day)
Why elderly people are at risk?
The elderly and the sick – may have an immune
response that is dangerous. It’s called a “cytokine storm,” when immune cells
are overproduced and flood into the lungs, causing pneumonia, inflammation and
shortness of breath.
Which occupation person are
at risk of death?
Patients who reported being retirees had the highest case fatality rate
at 5.1 per cent.
Does it affect all sexes?
56% are males. Although men and women have been infected in roughly equal numbers, the
death rate among men was 2.8 percent, compared with 1.7 percent among women.
Does it affect all ages?
87% aged 30-79
10% aged < 20
3% aged > 80
What is the incubation period?
·
Variable, 2-14 days (mean
3 based on 1,324 cases, 5.2 days based on 425 cases, 6.4 days in travellers
from Wuhan)
·
24 days has been observed.
WHO said it could reflect a second exposure rather than a long incubation
period. Hubei Province local government on Feb. 22 has reported a case with an
incubation period of 27 days.
What are different numbers?
·
Mean time to symptoms: 5
days
·
Mean time to pneumonia: 9
days.
·
Mean time to death: 14
days
·
Mean time to CT changes:
4 days
·
Reproductive number (R0
or R not): Number of persons infected by one infected person. In COVID 19 it is
3-4
·
R0 of flu: 1.2
·
R0 SARS 2
·
Epidemic doubling time: 7.5
days
·
Epidemic doubling time
in S Korea: 1 day, Probably due to super spreader?
·
Epidemic tripling time: S
Korea 3 days again due to a super spreader.
What is the positivity rate in contacts who
are tested?
UK 0.2%, Italy 5.0%, France 2.2%, Austria 0.6% and USA 3.1%
Which countries
one should not travel?
·
Level 1 in all countries (Exercise normal standard
hygiene precautions)
·
Level 2 in all affected countries (Exercise a high
degree of caution)
·
Level 3 in all countries with secondary cases
(Reconsider your need to travel)
·
Level 4 in affected parts of China and S Korea, Iran,
Italy (Do not travel)
Is it a Zoonotic disease?
Zoonotic
and linked to Huanan Seafood Wholesale Market as 55% with onset before January
1, 2020 were originated there but only 8.6% of the subsequent cases. The
Chinese government has banned the wildlife trade until the epidemic passes.
Is it linked
to bats?
It is closely related
to several bat coronaviruses. Bats are the primary reservoir for the virus.
SARS-CoV was transmitted to humans from exotic civet animals in wet markets, whereas
MERS-CoV is transmitted from camels to humans. In both cases, the
ancestral hosts were probably bats. Snakes and pangolins have been thought to
be the intermediate host. One thing is clear the origin is from a mammal.
What are different types of transmissions?
·
Droplets, large > 5-micron
organisms, flu, corona.
·
Air borne, < 5-micron
organisms, TB, chicken pox, measles.
·
Contact on the surface:
COVID 19, SARS, Flu [It
may be possible that a person can get COVID-19 by touching a surface or object
that has the virus on it and then touching their own mouth, nose, or possibly
their eyes]
Which are more important droplet precautions
or contact precautions?
Both. In community spread contact precautions becomes more important.
In SARS in Hong Kong the contact precautions worked more than the droplet
precautions.
Can it transmit from pregnant mother to
the baby?
No
or little evidence to support the possibility of vertical transmission from the
mother to the baby. [Lancet Feb 20]
Which part of the respiratory tract it effects?
·
Both upper and lower respiratory tract.
·
URTI causes fever with sore throat and mild
cough.
·
LRTI causes fever with cough, and
breathlessness.
·
Which is
more contagious LRTI or URTI?
·
COVID 19
uses the same cellular receptor as SARS-CoV (human angiotensin-converting
enzyme 2 [hACE2]), so transmission is expected more after signs of
lower respiratory tract disease develop.
·
COVID 19 grows better in primary human airway
epithelial cells than in standard tissue-culture cells, unlike SARS-CoV or MERS-CoV.
It is likely that COVID 19 will behave more like SARS-CoV.
Why LRTI is more infectious?
·
SARS is high [unintelligible] kind of inducer. This means
that when it infects the lower part of the lung, the body develops a very
severe reaction against it and leads to lots of inflammation and scarring.
·
In SARS after the first 10 to 15 days it wasn’t the virus
killing the patients it was the body’s reaction. Is this virus in the MERS or
SARS kind picture or is this the other type of virus which is a milder coronavirus
like the NL63 or the 229? It may be the mild (unintelligible) kind inducer. [Dr
John Nicholls University of Hong Kong]
What is the clinical presentation?
·
Clinically all patients
have fever (subjective or evident). No fever no corona.
·
75% have cough
·
50% weakness
·
50% breathlessness
·
Low total white count
·
Deranged liver enzymes.
· It starts with fever, followed
by a dry cough. After a week, it can lead to shortness of breath, with
about 20% of patients requiring hospital treatment.
Notably, the COVID-19 infection rarely seems to cause a runny nose, sneezing, or sore throat (these symptoms have been observed in only about 5% of patients). Sore throat, sneezing, and stuffy nose are most often signs of a cold.
Notably, the COVID-19 infection rarely seems to cause a runny nose, sneezing, or sore throat (these symptoms have been observed in only about 5% of patients). Sore throat, sneezing, and stuffy nose are most often signs of a cold.
How many need admission and ICU care?
20% need ICU care and
15% of them are fatal. Those cases categorised as critical has the highest fatality rate—at 49.0
per cent.
What is the treatment?
Symptomatic though chloroquine, anti-viral & anti-HIV
drugs have shown some efficacy.
What do you mean by Public Health Emergency of International
Concern?
COVID
19 was declared as PHEIC on 30th Jan 2020 which means it is mandatory
to report to WHO each human and animal case.
Is it the first time that a PHEIC has been declared?
·
No, Prior 5 PHEIC’s ARE
·
26th April 2009 - 10th August 2010
Swine flu
·
May
2014 Polio:
resurgence of wild polio
·
August
2014 Ebola:
It was the first PHEIC in a resource-poor setting
·
Feb 1, 2016 to 18 Nov 2016 Zika
·
2018–20 Kivu Ebola
What is Public Health Emergency of a state?
·
Kerala declared it when
it had three cases and later lifted it on 12th Feb.
·
San Francisco declared
it even without a case on 26th February.
·
Washington declared a
state emergency on 1st March
Did China delay in reporting of cases?
·
While there were 300 cases and 5 deaths with
SARS before the Chinese government reported it to the World Health
Organization, there were only 27 cases and no deaths with COVID-19 before it
was reported to that agency.
·
Chinese authorities-imposed lockdown measures
on ten cities in an unprecedented effort to contain the outbreak of corona
virus and built a specialized hospital [Huoshenshan Hospital] in just 10 days
as part of China’s intensive efforts to fight corona virus. A second facility
with 1,500 beds is also being opened. During SARS in 2003, a facility in
Beijing for patients with that viral disease was constructed in a week.
What are lab confirmed Cases?
Positive
throat swab test.
What are CT positive cases?
CT showing pneumonia
like changes
What is total number?
·
Lab
confirmed + CT Diagnosed Cases
·
This
was the criteria used from 12-19 February in China.
·
Before
and after only lab confirmed cases are counted.
·
Sudden jump in deaths
and new cases on 12th is due to inclusion of CT diagnosed cases.
What will be the estimated deaths if CT diagnosed cases were also
included?
Around
5% deaths will get added to total deaths.
What are
the possible modes of spread? Myths and facts
·
Person-to-person: Yes, the virus can
spread from one person to another, most likely through droplets of saliva or
mucus carried in the air for up to six feet or so when an infected person
coughs or sneezes, or through viral particles transferred when shaking hands or
sharing a drink with someone who has the virus.
·
Casual exposure: No, Human to human
contact requires prolonged contact (possibly ten minutes or more) within three
to six feet. But with contact transmission this may not be applicable.
·
Currency notes: The central banking authorities of
China are disinfecting, stashing and reportedly even destroying cash to stop
the spread of the coronavirus. People’s Bank of China says that the cash
collected by commercial banks must be disinfected before being released back to
customers.
·
Fabric,
carpet, and other soft surfaces: Currently, there’s no evidence.
·
Hard
surfaces: Virus could be on
frequently-touched surfaces, such as a doorknob, although early information
suggests viral particles would be likely to survive for just a few hours (WHO).
·
Biometric attendance: Maharishi Valmiki
hospital in Delhi stops biometric attendance
·
Kissing: Kissing
scenes have been banned in movies in China. France have advised to cut
back on “la bise,” the custom in France and elsewhere in Europe of giving
greetings with kisses, or air kisses, on the cheeks.
·
Breath analyser
for alcohol: Kerala exempted air crew from
breath analyser tests
·
Public gatherings: Affected countries have banned death
ceremonies, people gathering.
·
Uncovered eyes: The transmission is through mucus
membra contamination. One case got infected while using gown, but eyes not
covered.
·
Eating meat, fish or Chicken: Its not a food
borne illness but a respiratory illness. It cannot occur by eating any food or
meat. However, it is always advised not to touch raw meat, eat raw meat or eat
partially cooked meat to prevent meat related food borne illnesses. Eating fish
and chicken is safe.
·
Eating snakes or drinking bat soups: No eating
wild animals cannot cause it. Handling their secretions can cause it.
·
Handling wild animals or their meat: Yes, if their secretions
are handled by the animal handlers.
·
Semen: We do not know, in patients infected with
Ebola, the virus may persist for months in the testes or eyes even after
recovery — and can infect others and keep the
epidemic going.
·
Sex
like EBOLA and ZIKA: We have
no evidence yet.
·
Goods for affected areas: People receiving packages from China or other
affected areas are not at risk of contracting the COVID 19 as the virus does not survive long on objects,
such as letters or packages.
·
Pipes: Ventilation system connects one room to the next. There has
been previous concern that the coronavirus can spread through pipes
·
Stress: Stress and anxiety are
known to suppress the immune system, making people more susceptible to
contracting the virus.
·
Patients without symptoms: Both SARS-CoV and MERS-CoV infect intrapulmonary
epithelial cells more than cells of the upper airways. Consequently, transmission
occurs primarily from patients with recognized illness and not from patients
with mild, nonspecific signs. Though NEJM has reported a case of COVID 19 infection acquired outside of Asia
in which transmission of mild cases appears to have occurred during the
incubation period in the index patient but the same has been challenged now.
What is no contact policy?
Greeting
people by namaste, bowing or elbow touch. Corona Namaste is a no contact policy in
public. Let’s not shake hands, IMA and CMAAO promotes the concept of Corona Namaste.
Why the cases did not occur in other countries in the initial
phase?
Initial
serious illness in other countries were less as patients with breathlessness were
unlikely to board and patients will mild illness or asymptomatic illness are
less likely to transmit infections. Foer transmission you require cough secretions
or nasal discharge.
Should we fear?
It’s
time for facts, not fear; for rationality, not rumours and for solidarity, not
stigma.
What is the Help line number?
23978046
What is a biphasic infection?
Coronavirus follows what is known as a biphasic infection: the virus
persists and causes a different set of symptoms than observed in the initial bout.
The recovered person, too, can develop other symptoms, including insomnia and
neurological problems, said Angela Rasmussen, a virologist at Columbia
University.
What is a
spreader and a super spreader?
Spreader: An infected
person with normal infectivity.
Super
spreader
·
An
infected person with high infectivity, can infect hundreds of cases in no time.
What cause a person to become super spreader is not known, HIV person becomes a
super spreader if he or she is coinfected with STI.
·
The
examples are the first case in Wuhan, a female in the S Korea Daegu fringe Christian group Shincheonji
Church where she (61 years) infected more than 51 were infected.
·
In the church people shout out 'amen' after
every sentence the pastor utters, pretty much every few seconds. And they do
that at the top of their lungs, sending respiratory droplets flying everywhere.
What can
be the cause of a cluster of cases or a hot spot without a super spreader?
People catching the
virus from infected surfaces. We don’t know how long the germs stay on
surfaces, but similar viruses can live for a week.
What are the various
clusters of corona viruses?
· The
largest cluster was the Wuhan itself where over five crore people were locked
down ending up with over 2000 deaths.
· The
second largest lockdown was in Japanese diamond princess ship where over 3000
patients were locked up and 23% of them developed COVID 19 virus infection.
· The third
example the cult church in South Korea where one lady infected with the virus
spread it to over 30 people attending the church and she also infected multiple
people in a hospital where she was treated and one person later died.
· Shandong province in China reported that 207 cases
of the new coronavirus were reported in Rencheng prison as of Feb. 20, citing
information from the provincial government. A jail in the Zhejiang province has
also reported a total of 34 infections. All of them are inmates, according to
Chinese media. A jail will behave like a
ship and end up with 21% getting infected.
Can the court take cognigence in
corona epidemic?
·
Despite CDC
protest, 14 Americans infected with coronavirus on the Diamond.
Princess cruise ship shared a plane back to the U.S. with healthy passengers,
separated by plastic sheeting. (New York Post)
·
A
court temporarily blocked the U.S. government from sending up to 50 people
infected with a new virus from China to a Southern California city for quarantine
after local officials argued that the plan lacked details about how the
community would be protected from the outbreak.
· Hong Kong police this week nabbed
a part-time security guard at a shopping mall for allegedly writing on social
media that multiple staff members had caught a fever and gone on sick leave.
The messages "caused panic" and helped "breed paranoia".
· The government separately blamed
"evil" rumour-mongers for fuelling a run on goods at supermarkets such
as toilet paper and rice.
·
Singapore
has announced severe penalties for non-compliance of the quarantine order,
including fines or jail time.
·
Prosecutors
may investigate the founder and top leaders of Shincheonji Church of Jesus,
whose members account for > 60% of confirmed cases on murder and other
charges for failing to provide an accurate list of church members and by
interfering with the government’s efforts to fight the outbreak.
·
IPC: Section 270 in The Indian Penal Code: 270.
Malignant act likely to spread infection of disease dangerous to life.—Whoever
malignantly does any act which is, and which he knows or has reason to believe
to be, likely to spread the infection of any disease dangerous to life, shall
be punished with imprisonment of either description for a term which may extend
to two years, or with fine, or with both.
What do you mean by the word corona?
‘Corona’
means crown or the halo surrounding the sun. Heart is considered crown and
hence coronary arteries. In electron microscope, it is round with spikes poking
out from its periphery.
What is the composition of this virus?
It is a single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length, Beta corona virus from Corona family.
What are
other dreaded corona viruses?
·
COVID
19 is one of the three deadly human respiratory coronaviruses. Others are Severe
acute respiratory syndrome coronavirus [SARS-CoV] and Middle East respiratory
syndrome coronavirus [MERS-CoV]).
·
COVID
19 virus is 75 to 80% identical to the SARS-CoV
Where did it originate?
Wuhan,
China December 2019. 1st case informed to the world by Dr. Li Wenliang
who died on 6th Feb.
Will this virus survive heat?
Virus
is likely to be killed by sunlight, temperature, humidity. SARS stopped around
May and June in 2003 due to more sunlight and more humidity.
Did it originate from the WUHAN
bio terror lab?
Unlikely, nobody will procedure bioweapon to be
used on themselves or without simultaneously making an anti-weapon or antidote.
It’s a myth that the virus
was part of China's "covert biological weapons programme" and may
have leaked from the Wuhan Institute of Virology and was linked to the suspension
of a researcher at Canada's National Microbiology Lab.
Is it
true that China killed 20,000 COVID 19 patients?
It’s a fake news
linked to a diversion to a sex site.
In initial days does it has
high viral load.
Detection
of COVID 19 RNA in specimens from the upper respiratory tract with low Ct values
on day 4 and day 7 of illness is suggestive of high viral loads and potential
for transmissibility. [NEJM]
Was Diamond Princess ship quarantine a successful model?
·
Does not look like as 23% of cases got infected. 705 cases got the virus and 6 deaths and 36
still serious as on 1st march. Would mean 6 + 36x15 = 1-12 cases
will die.
·
The people on quarantine
are kept under a 14-day quarantine. If they are placed together and if anyone
is diagnosed during that period, the quarantine will add another 14 days.
·
The longer you have
several thousand people cohoused you will continue to propagate waves of
infection.
·
A better way to
quarantine is to break up these people into smaller groups and quarantine them
separately. Why quarantine children < 15 years when the virus is not risky
for them and why not separate elderly people with comorbid conditions at high
risk of deaths and quarantine them separately in one to one or small groups.
How long was the quarantine in the ship?
14
days for the passengers and another 14 fays for the crew who took care of the
people in the first 14 days.
What are different ways to control the infection in the community?
·
Lockdown in China: Unprecedented quarantines
across Hubei, locking in about 56 million people, in a bid to stop it
spreading. Results 2% deaths,
· Locking of a village in
Vietnam: More than 10,000 people
in villages near Vietnam's capital were placed under quarantine on 13th
February after six cases of the deadly new coronavirus were discovered there. These
cases did not become a hotspot probably there was no super spreader kin those cases.
Only 16 cases are so far.
· Kerala model of containment in India: Hospital one to one quarantine of infected patients and individual
home quarantine of contacts. They could contain the virus in the state.
Was it correct for India to have cultural evenings by quarantine
people brough from China?
It
was risky to allow people to celebrate and have cultural programs during
quarantine. As was seen in India people dances together with surgical masks
during quarantine period,
Is there a role of quarantine in the sunlight?
Quarantine
them like TB sanitoriums with both sun-balconies and a rooftop terrace where
the patients would lie all day either in beds or on specially designed chairs.
What should one wear at the triage section of
emergency room?
Surgical 3 layered mask to the patient; Isolation of two
beds with at least three feet distance, Cough etiquette and Hand hygiene for
all.
What are different precautions?
·
Droplet precautions: Three-layer surgical mask
by patients, their contacts and health care workers, in an adequately
ventilated isolation room, health care workers while caring with the secretions
should use eye protection, face shields/goggles. One should limit patient
movement, restrict attendants and observe hand hygiene.
·
Contact
precautions: When entering room - gown, mask, goggles, gloves – remove before
leaving the room; Dedicated equipment/ disinfection after every use; Care for
environment- door knobs, handles, articles, laundry; Avoid patient transport
and Hand hygiene
·
Airborne
precautions when handling virus in the lab and while performing aerosol-generating procedures: Room
should be with negative pressure with minimum of 12 air changes per hour or at
least 160 litres/second/patient in facilities with natural ventilation. There
should be restricted movement of other people and all should use gloves,
long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95
or equivalent, or higher level of protection)
What are
the precautions for general public?
·
Strict
self-quarantine if sick with flu like illness: 2 weeks
· Wash your hands often and for at least 20 seconds with soap and water or
use an alcohol-based hand sanitizer.
· Avoid touching: Eyes, nose, and mouth
with unwashed hands.
· Avoid close contact: (3-6 feet) with people who are sick with cough or
breathlessness
· Cover your cough or sneeze with a tissue, then throw the tissue in the
trash.
· Clean and disinfect frequently touched objects and surfaces.
Which masks for which patients?
·
Surgical 3 layered Masks: For patients and close contacts
·
N 95 Masks: For health care providers when handling respiratory
secretions.
What are
the lab tests?
There
are two ways to detect a virus: through the genetic material DNA or RNA or to
detect the protein of the virus. The rapid tests look at the protein. It takes
8-12 weeks to make commercial antibodies. So right now, for the diagnostics
tests they are using PCR which give you a turnaround in 1-2 hours.
What are false positive and false negative results?
·
PCR tests may detect remnants of the measles
virus months after people who had the disease stop shedding
infectious virus.
·
Negative test can be if the test is done poorly, or
the samples are stored at a temperature at which the virus deteriorates. The throat
swab may also simply miss the virus that is hiding elsewhere in the body.
·
A virus test is positive if the virus is there on
the swab in sufficient quantities at the time you swabbed the person. A
negative test is not a definitive that there is no more virus in that person.
Can you give an analogy of a negative test?
A jam jar with mold on top. Scraping off the surface might give the
impression that the jam is now mold-free, but in fact the jar may still contain
mold that continues to grow.
What samples to collect?
BOTH
the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower
respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or
bronchoalveolar lavage). Use viral swabs (sterile Dacron or rayon, not cotton)
and viral transport media
Can it be done by private labs?
Not yet
in India. In US in January, all testing had to be done in CDC
laboratories. However, on February 4, the US FDA issued an emergency-use
authorization for the CDC's COVID 19 Real-Time RT-PCR Diagnostic Panel, which
allows it to be used at any CDC-qualified laboratory in the United States.
What precautions
to take in the lab?
BSL 2 (3 for viral
culture labs)
Why pharma companies did not make SARS vaccine?
·
With SARS, in 6 months
the virus was gone, and it never came back. Companies may not spend millions to
develop a vaccine for something which may never come back.
·
The UN agencies should
have initiated the development of vaccine against corona virus, SARS or MERS strain,
if that was available, it might have reduced the case fatality of COVID 19.
Can it cause secondary infection?
Secondary
infection, E Coli, are most likely the cause of deaths of the patients in the
Philippines and HK.
Is there any proven treatment?
No
Which anti-viral have been tried?
· A combination of lopinavir and ritonavir showed promise in lab in SARS.
Combination of lopinavir, ritonavir and recombinant interferon beta-1b was
tried in MERS.
· Scientists in
Australia have reportedly recreated a lab-grown version of COVID 19.
·
Is chloroquine
effective?
·
Chloroquine had potent
antiviral activity against the SARS-CoV, has been shown to have similar
activity against HCoV-229E in cultured cells and against HCoV-OC43 both in cultured
cells and in a mouse model.
·
Is there any role of anti-HIV
drugs?
·
In Thailand Oseltamivir along
with lopinavir and ritonavir, both HIV drugs have been used successfully.
·
The Drug Controller
General of India has approved the "restricted use" of a combination
of drugs (Lopinavir and ritonavir) used widely for controlling HIV infection in
public health emergency for treating those affected by novel coronavirus.
·
What
is the role of experimental drug Rrom Gilead Sciences Inc., called remdesevir?
·
On
6th Feb in China and late February in USA trial has started.
· Russia and China drug: Arbidol, an antiviral drug used in
Russia and China for treating influenza, could be combined with Darunavir, the
anti-H.I.V. drug, for treating patients with the coronavirus. {the COVID 19
shares some similarity to HIV virus also)
What are other treatments tried?
·
PVP-I mouthwashes and gargles significantly
reduce viral load in the oral cavity and the oropharynx. PVP-I has high potency
for viricidal activity against hepatitis A and influenza, MERS and SARS
·
In SARS, people were put-on long-term steroids ending with
immunosuppression and late complications and death. The current protocol is
short term treatment.
·
Pneumococcal vaccine and Hib vaccine do not
provide protection against COVID
19.
· Regularly rinsing the nose
with saline does not protect people from infection with COVID 19 or respiratory infections
although it can help people recover more quickly from the common cold.
·
There is no evidence
that using mouthwash will protect you from infection with COVID 19 although some brands or
mouthwash can eliminate certain microbes for a few minutes in the saliva in
your mouth. Keep your throat moist, avoid spicy food and
load up on vitamin C can not kill the virus.
· There is no evidence that eating garlic protects people
from COVID 19.
· Sesame oil does not kill the new coronavirus. Chemical
disinfectants that can kill the COVID 19 on surfaces are bleach/chlorine-based
disinfectants, either solvents, 75% ethanol, peracetic acid and chloroform.
· Antibiotics do not work against
viruses.
Can dog/pets
get the COVID 19 virus?
There is no evidence.
Who is more vulnerable?
People with pre-existing medical conditions (such as asthma, diabetes,
heart disease) appear to be more vulnerable to becoming severely ill with the
virus.
What are various fake news?
·
COVID 19 linked to Donald Trump, US intelligence agencies or pharmaceutical
companies.
·
Avoiding cold or preserved food and drinks,
such as ice cream and milkshakes, for "at least 90 days can help.
·
Experts have been aware of the virus for years: The virus is not new,
its two deadly forma have already caused SERS and MERS in the world. These
types of viruses will keep on coming.
What is the role of CMAAO and other Medical Associations?
Get prepared for containment, including active
surveillance, early detection, isolation and case management, contact
tracing and prevention of onward spread of the virus and to share full
data with WHO. All countries
should emphasise on reducing human infection, prevention of secondary transmission
and international spread. Intensify IEC activities.
CMAAO IMA
FOMA MAMC Recommendations
Prise control of PPE;
accreditation of private labs for testing; private insurance should cover the
infection; IEC and CME activities to be intensified; allow paid leaves for air
born and droplet infections; allow teleconsultations in flu like diseases; CSR
funds for vaccine research; Surgical three-layered masks at public places; Start
National program on respiratory secretions born illnesses; in India incorporate
respiratory infection control under swatch bharat
How to suspect a corona case?
· CDC has already revised it Criteria to Guide Evaluation of PUI (person
under investigation) for COVID-19
· Fever or signs/symptoms of lower respiratory illness (cough or shortness
of breath) AND Any person,
including health care workers who has had close contact with a
laboratory-confirmed4 COVID-19 patient within 14 days of symptom onset
· Fever and signs/symptoms of a lower respiratory illness (cough or
shortness of breath) requiring hospitalization AND
A history of travel from affected geographic areas (China, Iran, Italy, Japan,
South Korea) within 14 days of symptom onset
· Fever with severe acute lower respiratory illness (pneumonia, ARDS) requiring
hospitalization and without alternative explanatory diagnosis (e.g., influenza)
AND No source of exposure has been identified.
What is a Probable case?
A suspect case for whom testing for
COVID 19 is inconclusive or for whom testing was positive on a pan-coronavirus
assay.
What
is a confirmed case?
A person with laboratory confirmation
of COVID 19 infection, irrespective of clinical signs and symptoms.
What is uncomplicated
illness?
Patients
with uncomplicated upper respiratory tract viral infection, may have non- specific
symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache,
muscle pain or malaise. The elderly and immunosuppressed may present with
atypical symptoms. These patients do not have any signs of dehydration, sepsis
or shortness of breath
What do you mean by close
contact?
Close
contacts are people providing direct care to patients, working with infected
health care workers, visiting infected patients or staying in the same close
environment, working together in close proximity or sharing the same classroom
environment with an infected patient, traveling together with infected patient
in any kind of conveyance, living in the same household as an infected patient.
The epidemiological link may have occurred within a 14-day period before or
after the onset of illness in the case under consideration. But once the community spread occurs the
definition will no longer be correct.
What is the definition of different
cases?
·
Primary case: Who got infected first in Wuhan in China?
·
Secondary case: When the primary cases infected the
second person and tertiary when the secondary cases transmitted to another person.
·
Primary case: The first case in the China Wuhan in
late December.
·
Index case: The first case in any country or the
province.
What is community spread?
Means
when the infection spreads without any contactable contact. Once that happens closing
borders will not contain the virus. All cases with flu like illness will be
presumed to be VOVID 19 AND ONLY patients with breathlessness will be tested.
What are mitigation guidelines?
·
Universal
non-pharmaceutical interventions include personal practices, covering coughs
and washing hands, as well as community and environmental measures such as
surface cleaning.
·
Universal
community measures include social distancing, or limiting contact in face-to-face
settings, closing schools, telework or tele school for children, and
recommending “modify, postpone, or cancel mass gatherings.
·
In healthcare
system triaging patients, conducting patient visits via telemedicine, and
delaying elective surgeries.
·
Commercial
labs need to pitch in for testing.
·
Better to
be overprepared than underprepared.
·
The
testing criteria may change to testing only symptomatic cases and admitting
cases only with breathlessness. (probably Iran is doing this)
What are high risk countries?
China,
Macau, Hong Kong, Taiwan, South Korea, Singapore, Italy, Iran, and
Japan.
Will Iran be the next China?
·
With
54 deaths in Iran, looks like that Iran government is hiding the true extent of
the outbreak. If the virus kills about 2 percent of known victims, then the
number of cases should be 2100. Infact the death rates outside china are 1% and
in that case the number will be much higher in Iran.
·
Cases
in Iraq, Afghanistan, Bahrain, Kuwait, Oman, Lebanon, United Arab Emirates and
Canada have been traced to Iran. Iran borders are crossed each year by millions of religious
pilgrims, migrant workers and others, is one of the biggest causes for
worry in what threatens to become a global epidemic.
Will afghan be the next source of
carrying infection in India?
·
Religious
pilgrims, migrant workers, businessmen, soldiers and clerics all flow
constantly across Iran’s frontiers, often crossing into countries with few
border controls, weak and ineffective governments and fragile health systems.
· Many
Afghanis are coming to India daily on health visa and many of them come via
Iran. It is likely many of them would carry the virus to India.
What is the role of 14 days quarantine?
Quarantines and travel restrictions now in place in many counties,
including the US, are also intended to help break the chain of transmission.
Public health authorities like the CDC may recommend other approaches for
people who may have been exposed to the virus, including isolation at home and
symptom monitoring for a period of time (usually 14 days), depending on level of risk for exposure.
Should I wear a face mask to protect against
coronavirus?
Currently, face masks are not recommended for the general public. Some
health facilities require people to wear a mask under certain circumstances,
such as if they have travelled from the city of Wuhan, China or surrounding
Hubei Province, or other affected countries or have been in contact with people
who did or with people who have confirmed coronavirus.
If you have respiratory symptoms like coughing or sneezing, experts
recommend wearing a mask to protect others. This may help contain droplets
containing any type of virus, including the flu, and protect close contacts
(anyone within three to six feet of the infected person).
Should someone who is immunocompromised wear a
mask?
Only if you are attending a public function. However, if your healthcare
provider advises you to wear a mask when in public areas because you have a
particularly vulnerable immune system, follow that advice. But if masking has
not been recommended to you to protect against the flu and numerous other
respiratory viruses, then it doesn’t make sense to wear a mask to protect
against COVID-19.
Should I accept packages from China?
There is no reason to suspect that packages from China harbour COVID-19.
Remember, this is a respiratory virus like the flu. We don’t stop receiving
packages from China during their flu season. We should follow that same logic
for this novel pathogen.
Can I catch the coronavirus by eating food prepared
by others?
COVID-19 and other coronaviruses have been detected in the stool of
certain patients, so we currently cannot rule out the possibility of occasional
transmission from infected food handlers. The virus would likely be killed by
cooking the food.
Should I travel on a plane if I have fever?
Of course, if anyone has a fever and respiratory symptoms, that person
should not fly if possible, but anyone who has a fever and
respiratory symptoms and flies anyway should wear a mask on an airplane.
What should people do if they think they have coronavirus,
or their child does? Go to an urgent care clinic? Go to the ER?
Call your doctors instead of rushing to emergency room.
Can people who recover from the coronavirus still
be carriers and therefore spread it?
There is no current evidence?
Are we
missing infections in India?
We do not know. In Iran the country missed hundreds of cases till two persons
died. Infect the first case was the one who died.
Can people who recover from a bout with the new
coronavirus become infected again?
· The Japanese government reported that a woman in Osaka had tested positive for the coronavirus for a second time, weeks after
recovering from the infection and being discharged from a hospital. Combined with reports from China of similar cases, the case in Japan
has raised some questions. Reinfections are common among
people who have recovered from coronaviruses that
cause the common cold.
· Reinfection in a short time is unlikely. Even the mildest of infections
should leave at least short-term immunity against the virus in the recovering
patient. More likely, the “reinfected” patients still harboured low levels of the virus when they were discharged from the hospital,
and testing failed to pick it up.
· Even if there were occasional cases of reinfection, they do not seem to
be occurring in numbers large enough to be a priority at this point in the
outbreak.
How long the antibodies last?
Research
with MERS has shown that the strength of the immune response depends on the
severity of the infection, but that even in those with severe disease — which
should produce the strongest immune responses — the immunity seemed to wane within
a year.
Why SARS
never entered India except a few cases and neighbouring countries?
Either cases were not
detected or by the time it reached India there was already a summer.
Are
antibodies protective?
On Feb.
13, a Chinese senior health official called on people who had recovered from
the new coronavirus to donate blood plasma, because it might contain
valuable proteins that could be used to treat sick patients, according to The New York Times.
What is corona beer?
It has nothing to do
with coronavirus. It’s a brand of beer.
Why so
much rear when the mortality is < 1%
The population is
totally susceptible and in a country like India with huge population the deaths
in numbers will be very high.
When
deaths are less seen in people with age less than 50 years then why anxiety in younger
them?
The younger
population has more fear of getting quarantines for 14 days or fear of losing
their beloved elderly ones with comorbid conditions.
When
should I suspect corona cases in India?
H1N1 negative flu
like illness.
What is Environmental disinfection?
·
CDC states routine
cleaning and disinfection procedures are appropriate for COVID-19 virus.
Products approved by the Environmental Protection Agency for emerging viral
pathogens should be used.
·
SARS
and MERS, have been found to persist on inanimate surfaces, including metal,
glass or plastic surfaces, for as long as nine days if that surface had not
been disinfected, according to a research published in The Journal of Hospital
Infection.
·
Human
coronaviruses can be efficiently inactivated by surface disinfection procedures
with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite"
or bleach within one minute.
·
For
SARS coronavirus, the range of persistence on surfaces was less than five minutes
to nine days.
·
According
to the CDC, the flu virus can live on some surfaces for as long as 48 hours and
potentially infect someone if the surface has not been cleaned and disinfected.
In which conditions seasonal flu is more
dangerous?
The flu is more
dangerous to young children. Children infected with the new coronavirus tend to
have mild or no symptoms. It is also dangerous
for pregnant women. Whether the COVID 19 poses as serious a threat to pregnant
women is not known.
How many
people die of seasonal flu?
As of Feb. 22, in the current season there were at least 32 million cases of
flu in the United States, 310,000 hospitalizations and 18,000 flu deaths,
according to the C.D.C.
Can the
warm atmosphere kill the virus?
Coronavirus may retreat as
weather warms, just as influenza does. Because this is a new virus, there is no
information about how the weather might affect it.
Even if the virus
were to diminish in the spring, it might rebound later in the fall, as the
weather cools. This is a pattern often seen in severe flu seasons.
Can dengue coexist with COVID 19?
In Thailand a 35-year-old
man who was diagnosed with dengue and COVID-19 died. When combined with the emerging infectious disease,
it created complications leading to multi-organ failure.
What is
the preparedness in India?
The two designated hospitals
in Delhi are RML and Safdar Jang, both have an OPD of thousands of people. Ideally such OPDs should be held at places
where there no mix up with other types of patients.
Do we
have a China like make-shift hospital like facility in India?
Not so far.
How is
the India government coordinating with the IMA?
I am not aware of any
such meeting.
How many
Indian got Corona in the Diamond Princes ship
16
What is
the role of army in containment of any epidemic?
In March
2016 there was a biggest military
mobilisation in Brazil’s history: 220,000 army, navy and air force personnel were
called into action, as well as 315,000 public officials. The enemy was tiny Aedes
aegypti mosquito which is believed to be responsible for the spread of
the Zika virus.
What can happen if the disease spread in a
city?
·
Like
Diamond princess ship, quarantine will lead to 23% getting infected
·
Like
1200 who attended church 14% them have exhibited
cough and other symptoms
·
China
locked down 5 crore people with self-quarantine policy, 80,000 got infected (0.0016%
of the community) and 2760 deaths (0.0000552% of the population)
·
647,406 people close contact with infected patients (1:8
patients).
What is the expected number of cases in Delhi
in a Wuhan like situation?
·
Total
expected positive in 1.67 crore population = 26720
·
Likely
contacts: 213760
·
Expected
serious cases = 20% = 4008
·
Likely
deaths: 926
·
At
risk 60+ population In Delhi = 1164147
What will be the preparedness needed then in
Delhi?
4000 corona beds (15% of patients); self-quarantine of
17-20000 patients; no admission for patients without breathlessness; paid
teleconsultation of mild cases; ICU beds with ventilatory care 3% (801 beds); Listing
of hospitals with ECHMO machines; PPE 5 per patient (20,000 per day); Surgical
masks usage: 213760 per day; Hand
sanitisers: at least 2 lac per day; Health care providers dedicated with corona
handling training: 20,000; 250 persons trained in handling dead bodies of
infected cases; 500-1000 dedicated mental health councillors to tackled corona
anxiety; 20 corona spokesmen to speak the same language; Prize cap of masks,
other related diagnostics and PEPs; censoring of myths and fake news on social
media and earmarked and segregated
areas for Corona triage: suspect but not serious; suspect and serious; confirmed
but not serious and confirmed and serious?
What is
the role of CMAAO in COVID 19?
CMAAO
alerted
·
26 December 2019: viruses
like SARS detected and Chinese scientists alerted the world about it.
·
3 January 2020: Transition
from human to human raised concern
·
Despite this, on January 5,
the Wuhan administration mentioned that the illness doesn’t seem to unfold from
people to people. China lastly formally confirmed on 20 January that the corona
was spreading from human to human.
·
7th January: WHO to
monitor China's mysterious pneumonia of unknown virus outbreak?
·
8th: CMAAO warns Asian
citizens travelling China over mystery pneumonia outbreak
·
10th: It’s a new strain of
corona virus in the china pneumonia
·
13th Jan: China Virus Outbreak Linked to Seafood Market
·
15th Jan: 1st Case China
Pneumonia Virus Found in Thailand outside China.
·
21st Jan: New China
coronavirus can spread between humans
·
22nd Jan: New China virus
now in US, Thailand, Japan, South Korea and Taiwan: Will India or other Asian
countries be spared
·
23rd Jan: Corona Virus:
will it be declared as International Public Health Emergency by WH
·
11th 24th Jan: Corona
virus 1st Death Outside Wuhan Epicentre Is Reported. W.H.O. DECISION: Corona
virus is spreading, but the organization says it is not a global emergency
·
25th Jan: 25 Jan Indian
Govt should pay for the treatment of India trapped in China with Corona Virus
Since
than it has been covering daily.
The coronavirus COVID-19
is affecting 67 countries and territories around the world
and 1 international conveyance (the Diamond
Princess cruise ship harbored in Yokohama, Japan).
Search:
|
Country,
Other |
Total
Cases |
New
Cases |
Total
Deaths |
New
Deaths |
Active
Cases |
Total
Recovered |
Serious,
Critical |
|
China
|
80,026
|
+202
|
2,912
|
+42
|
32,616
|
44,498
|
7,110
|
|
S.
Korea
|
4,212
|
+1,062
|
22
|
+5
|
4,160
|
30
|
9
|
|
Italy
|
1,694
|
+566
|
34
|
+5
|
1,577
|
83
|
140
|
|
Iran
|
978
|
+385
|
54
|
+11
|
749
|
175
|
|
|
Diamond Princess
|
705
|
7
|
+1
|
688
|
10
|
36
|
|
|
Japan
|
256
|
+15
|
6
|
+1
|
218
|
32
|
19
|
|
France
|
130
|
+30
|
2
|
116
|
12
|
9
|
|
|
Germany
|
130
|
+51
|
114
|
16
|
2
|
||
|
Singapore
|
106
|
+4
|
32
|
74
|
7
|
||
|
Hong
Kong
|
100
|
+5
|
2
|
62
|
36
|
6
|
|
|
Spain
|
84
|
+26
|
82
|
2
|
3
|
||
|
USA
|
81
|
+13
|
2
|
+1
|
70
|
9
|
8
|
|
Bahrain
|
47
|
+6
|
47
|
||||
|
Kuwait
|
46
|
+1
|
46
|
||||
|
Thailand
|
42
|
1
|
+1
|
11
|
30
|
1
|
|
|
Taiwan
|
40
|
+1
|
1
|
27
|
12
|
1
|
|
|
U.K.
|
36
|
+13
|
28
|
8
|
|||
|
Australia
|
29
|
+4
|
1
|
+1
|
13
|
15
|
|
|
Malaysia
|
29
|
+4
|
7
|
22
|
|||
|
Canada
|
24
|
+4
|
20
|
4
|
|||
|
Switzerland
|
24
|
+5
|
23
|
1
|
|||
|
U.A.E.
|
21
|
16
|
5
|
2
|
|||
|
Iraq
|
19
|
+6
|
19
|
||||
|
Norway
|
19
|
+4
|
19
|
||||
|
Vietnam
|
16
|
0
|
16
|
||||
|
Austria
|
14
|
+4
|
14
|
||||
|
Sweden
|
14
|
+1
|
14
|
||||
|
Macao
|
10
|
4
|
6
|
||||
|
Israel
|
10
|
+3
|
9
|
1
|
|||
|
Lebanon
|
10
|
+3
|
10
|
||||
|
Netherlands
|
10
|
+3
|
10
|
1
|
|||
|
San
Marino
|
8
|
+7
|
1
|
+1
|
7
|
1
|
|
|
Croatia
|
7
|
+1
|
7
|
||||
|
Greece
|
7
|
7
|
|||||
|
Ecuador
|
6
|
+5
|
6
|
1
|
|||
|
Finland
|
6
|
+3
|
5
|
1
|
|||
|
Oman
|
6
|
5
|
1
|
||||
|
Mexico
|
5
|
+1
|
5
|
||||
|
Denmark
|
4
|
+1
|
4
|
||||
|
Pakistan
|
4
|
4
|
|||||
|
Philippines
|
3
|
1
|
0
|
2
|
|||
|
Algeria
|
3
|
+2
|
3
|
||||
|
Azerbaijan
|
3
|
3
|
|||||
|
Czechia
|
3
|
+3
|
3
|
||||
|
Georgia
|
3
|
3
|
|||||
|
Iceland
|
3
|
+2
|
3
|
||||
|
India
|
3
|
0
|
3
|
||||
|
Qatar
|
3
|
+2
|
3
|
||||
|
Romania
|
3
|
2
|
1
|
||||
|
Belgium
|
2
|
+1
|
1
|
1
|
|||
|
Brazil
|
2
|
2
|
|||||
|
Egypt
|
2
|
+1
|
1
|
1
|
|||
|
Russia
|
2
|
0
|
2
|
||||
|
Afghanistan
|
1
|
1
|
|||||
|
Armenia
|
1
|
+1
|
1
|
||||
|
Belarus
|
1
|
1
|
|||||
|
Cambodia
|
1
|
0
|
1
|
||||
|
Dominican
Republic
|
1
|
+1
|
1
|
||||
|
Estonia
|
1
|
1
|
|||||
|
Ireland
|
1
|
1
|
|||||
|
Lithuania
|
1
|
1
|
|||||
|
Luxembourg
|
1
|
1
|
|||||
|
North
Macedonia
|
1
|
1
|
|||||
|
Monaco
|
1
|
1
|
|||||
|
Nepal
|
1
|
0
|
1
|
||||
|
New
Zealand
|
1
|
1
|
|||||
|
Nigeria
|
1
|
1
|
|||||
|
Sri Lanka
|
1
|
0
|
1
|
||||
|
Total:
|
89,065
|
2,452
|
3,046
|
69
|
40,907
|
45,112
|
7,356
|
Highlighted in green
= all cases have recovered from the infection.
Highlighted in grey
= all cases have had an outcome (there are no active cases).
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